"The Supreme Court on Thursday upheld President Obama’s health reform law, affirming the centerpiece of the sweeping 2010 overhaul of the nation’s medical industries in a landmark 5-4 vote. The deciding opinion, written by conservative Chief Justice John Roberts, held that the requirement that almost all Americans buy health insurance starting in 2014 or pay a penalty, does not violate the Constitution. The Court limited a massive expansion of Medicaid, the federal program that provides health care to the poor, but did not strike it down. That outcome validates the legacy achievement of Obama’s tenure, and puts the U.S. closer to near-universal health coverage than at any time in its history.

You can read a copy of the decision at the bottom of this story. Here are the likely winners and losers in the ruling’s aftermath.

Winners
The Obama Administration. Beyond the obvious matter of being able to move forward with a major set of policies the Democratic party has wanted for decades, the Supreme Court’s stamp of approval on the Affordable Care Act legitimizes Obama’s most visible and far-reaching domestic achievement. It also undercuts Republicans’ charge that the Obama Administration has consistently overreached its authority. The Supreme Court’s decision says the government’s insurance requirement is a tax with precedent. In addition, a vote from right-leaning Chief Justice John Roberts further seals the argument that the law, while politically explosive, is nonetheless constitutional.

The sick and the uninsured. The Affordable Care Act will extend health insurance to some 30 million Americans who currently lack coverage. It will also guarantee the availability of insurance for those with pre-existing conditions and ensure those people don’t pay more than healthy people. Anyone earning up to 133% of the federal poverty level will get free coverage through Medicaid and those earning 133% to 400% (but without access to employer or government insurance) will be eligible for federal subsidies to help them buy policies.

Congressional Democrats. While health care reform will remain a potent political issue – just because it’s constitutional doesn’t mean everyone has to like it – Democratic Senators and House members who voted for the law won’t have to defend themselves against charges that they ran roughshod over the Constitution. Plus, those campaigning this year will be able to publicize the popular elements of the law.

The Court’s political reputation. It’s unlikely that Republicans will charge this High Court with partisanship in the wake of its ruling on Obamacare. But if the court had struck down the law, there were clear signs that many Democrats were going to demonize the justices as overly political, a criticism that’s grown louder in recent years following controversial cases like Bush v. Gore and Citizens United v. FEC.

Mitt Romney. Yes, a major policy Romney opposed has been upheld, which looks like a Romney defeat. But now that the effort to nix the law via the courts has failed, Romney can argue that the only way to get rid of Obamacare is to elect him. That message will resonate with Republicans and independents who intensely dislike the law.

Losers
Congressional Republicans. Scores of congressional Republicans formally signed onto legal challenges to Obamacare. House GOP members have also been trying to get rid of the Affordable Care Act via “repeal” votes. Neither effort has done anything to change the status quo. Congressional Republicans can tell voters they tried their best to get rid of Obamacare, but in terms of showing results, they’ve come up short. Still, like Romney, members of Congress up for re-election this fall can argue the only way to get rid of (or slow) Obamacare is to vote for them.

Republican Governors. The Affordable Care Act is a federal law, but it’s written to be largely administered at the state level. Most states with Republican governors put off steps to implement the law while they waited to see what the Supreme Court would do. This has left them far behind states with Democratic governors who were eager to start setting up new programs—like consumer assistance offices—called for by the ACA, and funded by federal grants. Republican states also largely decided not to begin setting up health insurance exchanges, the marketplaces where federal subsidies will be doled out, and where individual and small group insurance policies will be sold. The exchanges won’t begin operating until 2014, but states have to prove to the federal government they’re equipped to run them long before that and some Republican states that have held out might not make the deadline. In these cases, the federal government will step in, set up an exchange and run it. This means these Republicans leaders will have to explain that they inadvertently invited more federal control in their effort to resist Obamacare.

Young People (sort of). The requirement to buy insurance, which has been upheld along with the rest of the ACA, is largely designed to pull currently uninsured young, healthy people into the system.These people often forgo insurance because they make the fairly good bet they won’t incur expensive medical bills and because they don’t have enough earning power to afford policies. Young Americans subject to the mandate are expected to pay more into the insurance pool than they get out, to help subsidize the cost of insuring older, sicker people. Standard insurance policies will likely be more expensive for these people under the ACA than they are now. Still, the ACA allows young adults to satisfy the mandate with low-cost catastrophic health insurance policies if they choose—everyone else will be required to buy standard insurance—and if they’re under 26, they can get insured through their parents’ plans."

No. Like in many other developed, Western countries, all Americans must have health care coverage, which they'll pay for, but there are a variety of mechanisms to ensure that people will be able to afford the coverage.

Quote:

The sick and the uninsured. The Affordable Care Act will extend health insurance to some 30 million Americans who currently lack coverage. It will also guarantee the availability of insurance for those with pre-existing conditions and ensure those people don’t pay more than healthy people. Anyone earning up to 133% of the federal poverty level will get free coverage through Medicaid and those earning 133% to 400% (but without access to employer or government insurance) will be eligible for federal subsidies to help them buy policies.

No. Like in many other developed, Western countries, all Americans must have health care coverage, which they'll pay for, but there are a variety of mechanisms to ensure that people will be able to afford the coverage.

Quote:

The sick and the uninsured. The Affordable Care Act will extend health insurance to some 30 million Americans who currently lack coverage. It will also guarantee the availability of insurance for those with pre-existing conditions and ensure those people don’t pay more than healthy people. Anyone earning up to 133% of the federal poverty level will get free coverage through Medicaid and those earning 133% to 400% (but without access to employer or government insurance) will be eligible for federal subsidies to help them buy policies.

What about expats, are we supposed to buy insurance that they recognize?

Has this issue been addressed and defined? The US taxes its citizens who reside and earn abroad (regardless of the 90k+ exemption). Won't they also require you to pay into this healthcare system?

as i understand it, expats must have proof of insurance. but would they
accept $200/year PICC insurance provided by chinese employers?

the big questions are how will this massive system be instituted, and
how will it be enforced? and how much will it REALLY cost? i suspect the
overall cost to the consumer will double or triple. why? hospitals and
insurers and lobbying groups helped draft the law. they will win in the
end. medical costs will continue to rise, possibly even faster, but now
we'll have the massive costs of the national health bureaucracy as well.

you've seen the results of government programs in the us. you've seen
$700 hammers and $3000 toilet seats. so get ready for the $10,000
colonoscopy. (to save costs, as at the government VA hospitals, they
won't sterilize the probes between uses.)

2.The requirement to purchase coverage affects U.S. citizens and U.S. visa holders only if they actually live in the U.S. This is because these individuals are most likely to receive treatment in the U.S. Therefore, actual citizenship does not matter in this mandate. Instead, it is their legal residency that will be considered

2.The requirement to purchase coverage affects U.S. citizens and U.S. visa holders only if they actually live in the U.S. This is because these individuals are most likely to receive treatment in the U.S. Therefore, actual citizenship does not matter in this mandate. Instead, it is their legal residency that will be considered

If I understand correctly, it's an analysis of the mandates of the plan and their consequences for expats.

Keep in mind it's not a new law package - it was passed a couple of years ago. Yesterday's Supreme Court ruling didn't change any of the provisions in the package, so a two-year-old analysis of specific aspects of the law is still valid.

I posted it in response to the queries regarding how the health care plan affects expats.

Actually, if we'd been immediately required to have US-approved coverage, it would already have been in effect. The info in the link shows that there is no future plan in the current law to make demands of US expats either to pay a health care tax in the US or to buy US-approved health care packages while abroad.

"you've seen the results of government programs in the us. you've seen
$700 hammers and $3000 toilet seats. so get ready for the $10,000
colonoscopy. (to save costs, as at the government VA hospitals, they
won't sterilize the probes between uses.)"

Yes, as a matter of fact, I have - close up and very personal. As a former Marine and Vietnam vet, I've had four colonoscopies (ulcerative colitis), a prostatectomy, removal of a bladder stone, and melanoma surgery at the VA hospital in Albuquerque, NM. The staff there are great, the treatment is first-class, and all those procedures were totally successful, with no problems. Sure, that's all "anecdotal", so let's look at the BIG picture:

You mentioned this: "to save costs, as at the government VA hospitals, they won't sterilize the probes between uses." which apparently did happen at one VA hospital (in Miami) although you make iot sound as if it were "standard procedure" at ALL VA hospitals, which it is most certainly not.

"Infections related to medical treatment are a problem at public and private hospitals nationwide. The VA, as a government entity, must report infections publicly but most public and private hospitals do not.

The Veterans Affairs system that serves about 6 million vets a year in more than 1,000 medical facilities has been praised by medical authorities for its successful efforts to reduce antibiotic-resistant staph infections from treatment, a common problem in U.S. hospitals. A study published last month in The New England Journal of Medicine reported VA hospitals reduced such infections by 60 percent in intensive care units around the country after three years of emphasizing hygiene education and sanitizer availability in its facilities.

Diane Pinakiewicz, president of the advocacy group National Patient Safety Foundation, agreed that VA health care has done exceptionally well on the problem of health care-associated infections, which the Centers for Disease Control and Prevention estimates afflict 1.7 million patients nationally, killing 99,000 people and costing up to $34 billion a year. Many hospitals have balked at pushes for greater transparency about infections, citing issues ranging from inconsistent reporting standards to patient privacy.

"It's not a small problem," she said. "It's something patients should be aware of and very concerned about."

VA officials say their overall record of providing care for veterans is strong, and that critics shouldn't generalize about VA care from the series of hospital infection cases in the last two years (2009 - 2011). The Disabled American Veterans, which represents some 1.2 million veterans, rallied to the VA's defense as criticism grew.

"VA health care is clearly the best anywhere and has been so deemed by numerous private entities," Wallace Tyson, the group's national commander, said in a statement late last year."

"The VA runs the largest integrated health-care system in the country, with more than 1,400 hospitals, clinics and nursing homes employing 14,800 doctors and 61,000 nurses. And by a number of measures, this government-managed health-care program--socialized medicine on a small scale--is beating the marketplace. For the sixth year in a row, VA hospitals last year scored higher than private facilities on the University of Michigan's American Customer Satisfaction Index, based on patient surveys on the quality of care received. The VA scored 83 out of 100; private institutions, 71. Males 65 years and older receiving VA care had about a 40% lower risk of death than those enrolled in Medicare Advantage, whose care is provided through private health plans or HMOs, according to a study published in the April edition of Medical Care. Harvard University just gave the VA its Innovations in American Government Award for the agency's work in computerizing patient records.
And all that was achieved at a relatively low cost. In the past 10 years, the number of veterans receiving treatment from the VA has more than doubled, from 2.5 million to 5.3 million, but the agency has cared for them with 10,000 fewer employees. The VA's cost per patient has remained steady during the past 10 years. The cost of private care has jumped about 40% in that same period.

"Overall Evaluation
"Patients routinely rank the veterans system above the alternatives, according to the American Customer Satisfaction Index." In 2008, the VHA got a satisfaction rating of 85 for inpatient treatment, compared with 77 for private hospitals. In the same report the VHA outpatient care scored 3 points higher than for private hospitals.[15]

"As compared with the Medicare fee-for-service program, the VA performed significantly better on all 11 similar quality indicators for the period from 1997 through 1999. In 2000, the VA outperformed Medicare on 12 of 13 indicators." [16]

A study that compared VHA with commercial managed care systems in their treatment of diabetes patients found that in all seven measures of quality, the VHA provided better care.[17]

A RAND Corporation study in 2004 concluded that the VHA outperforms all other sectors of American health care in 294 measures of quality; Patients from the VHA scored significantly higher for adjusted overall quality, chronic disease care, and preventive care, but not for acute care.

A 2009 Congressional Budget Office report on the VHA found that "the care provided to VHA patients compares favorably with that provided to non-VHA patients in terms of compliance with widely recognized clinical guidelines — particularly those that VHA has emphasized in its internal performance measurement system. Such research is complicated by the fact that most users of VHA’s services receive at least part of their care from outside providers."

VA Mental Health Services
The percentage of veterans seen at the VA with a mental illness was 15 percent in 2007. Trends show that the percentage of veterans with mental illnesses will continue to increase. The VA has directed its attention to this growing trend and is making mental health care for veterans a priority. For example, the VA allocated an extra 1.4 billion dollars per year to the mental health program between 2005 and 2008. They also implemented a five-year Mental Health Strategic Plan to expand and improve the mental health program. The status of the Mental Health program in 2006 was evaluated as a part of Mental Health Strategic Plan[18]. The results are as follows:

Quality of care at the VA was shown to be better than the private sector. The VA had a higher level of performance then the private sector for 7 out of 9 indicators. In fact, they “exceeded private plan performance by large margins[19].”
Patients did not indicate improvement in their conditions. However, they had a very favorable opinions of their care."

"I strongly disagree with the statement that government can't do anything right. I'd also note that 'the government' is us; and if it can't function effectively than we need look no further than the mirror. But it can, and does, work pretty well in many instances.

Among the numerous examples of relatively effective government are the Centers for Disease Control, US Coast Guard, National Oceanic and Atmospheric Administration, Head Start, AmeriCorps, NIH, the GI BIll, and the National Weather Service. No, none are perfect, but then again our private sector is not exactly stuffed with competence these days.

It is not the fact that an organization is 'government' or private that makes it competent or not, it is the leadership of that organization that is the determining factor.

But perhaps the best is the Veteran's Administration health care system. As I noted last month,

- compared to commercial managed care plans, the VA provided diabetics with better quality care on seven out of eight metrics by NCQA.

- In 2005, VA hospitals were the highest-rated health system, outperforming other systems including the Mayo Clinic and Johns Hopkins.

- for six years running, VA hospitals scored higher than private facilities on the University of Michigan's American Customer Satisfaction Index.

And costs haven't increased nearly as fast as they have in the private sector. In the ten years ending in 2005, the number of veterans receiving treatment from the VA more than doubled, from 2.5 million to 5.3 million, but the agency needed 10,000 fewer employees to deliver that care - as a result the cost per patient stayed flat. (costs for care in the private sector jumped 60% over the same period).

The VA did this by closing down unneeded facilities, developing an industry-leading electronic health record system, opening clinics, and dramatically increasing the quality of care, especially for patients with chronic conditions.

Oh, and patients can access their own health records - securely - anytime on the web.

Sounds pretty good to me. But alas, universal coverage will not result in the Feds running the health care system. The current proposals under consideration keep providers private (for-profit and not-for-profit), brokers will keep broking, insurance companies doing their thing. Yes, there may well (and should) be a public insurance option, but there is precious little evidence to suggest that the public option will dominate the market. And the evidence that is touted is not compelling.

In fact, providers would not have to participate in a public option - they could refuse to sign up if reimbursement was too low or other terms not to their liking.

And, the governmental option would have to compete with what is already a very mature market, dominated by very few healthplans with overwhelming market share. Here's just one statistic - In almost two-thirds of all HMO/PPO market areas, one healthplan has more than 50% market share.

Good luck to the Feds fighting for share in Texarkana where the Blues' share is 97%, or Gadsden Alabama (95%).

Finally, those arguing against UC with the 'government is incompetent' meme must not have followed the accounts of healthplans canceling coverage for individuals without justification, employing medical underwriting to refuse coverage for any pre-existing condition, using skewed data to avoid paying what they should for out of network care, fraudulently enrolling seniors in Medicare Advantage plans, and slashing provider bills with the thinnest of justifications.

It would take a good deal of hard work to be more incompetent than some of the health plans out there today.

So, tell me, choudoufu, how BAD the VA hospitals are. Please describe YOUR anecdotal experiences. Are VA hospitals perfect? Of course not, but I know that I'll take them any day over an HMO. Plus, of course, here's my total bill for all those procedures: $0